CF 048: Do Disc Herniations On An MRI Worsen When Sitting Or Standing (PART TWO)? - chiropracticforward CF 048: Do Disc Herniations On An MRI Worsen When Sitting Or Standing (PART TWO)? - chiropracticforward

CF 048: Do Disc Herniations On An MRI Worsen When Sitting Or Standing (Part TWO)?

Today we’re going to continue our talk from last week on whether or not a disc herniations change as you sit up, stand up, or move around. We went over some pretty good research last week. This week, it’s time for the cherry on the top. 

But first, here’s that bumper music

Integrating Chiropractors

 

OK, we are back. Welcome to the podcast today, I’m Dr. Jeff Williams and I’m your host for the Chiropractic Forward podcast.  

You have scampered into Episode #48. I use scamper this week because, as my son was playing with his aunt and uncle’s dog named Rowdy down in Dallas last weekend, that was the way he described when the dog would take off after the tennis ball every time. Scamper. Great word that I plan on using more from here on out where appropriate. 

Diplomate of Chiropractic Orthopedists

The DACO this weekend down in Dallas. The class was with James Lehman. Dr. Lehman, in case you do not know, is with the University of Bridgeport Connecticut. His official title from their website is Associate Professor of Clinical Sciences, Health Sciences, College of Chiropractic. 

Dr. Lehman is also one of the main drivers of this DACO program. Through Univ. of Bridgeport Connecticut, he has teamed up with CDI out of Australia and their courses in neuromusculoskeletal online education. It is VERY well done. Very professional and very worthwhile. You can find that at https://cdi.edu.au

We talked a lot about some stuff that I want you to hear straight from him so we’ll do an interview with him very soon but the gist of it all is this: get certified in something other than simply having your doctor of chiropractic degree. 

FQHC

I’ve heard a couple of opinions. I’ve heard the Diplomate programs are worthless now and that people are moving away from them. But, I think that’s coming from people that don’t want to take the time or put in the effort. The real story is most likely that our system, for good or bad, is moving away from private practice and TOWARD integrating through the group offices and through the Federally Qualified Health Centers. 

There are chiropractors being reimbursed in the system up to $300 for a Medicaid visit and around $150 on the lower end. 

I have to thank Dr. Craig Benton once again for bringing this to my attention. Did you guys know that, given the right positioning, you could make that much per appointment from freaking Medicaid?

Here’s the deal though: you have to be a specialist. A Diplomate. So, is it really useless? I say it most certainly is not. 

Whiplash Section

Now the course, the course this weekend was on whiplash. I’ve been through Art Croft’s 4 part Advanced Certification on Whiplash Biomechanics and Traumatology so I can say with a lot of honesty that a good portion of the course was a refresher for me. 

But, I absolutely learned a solid amount of new stuff as well. Such as Axillary compression. Axillary compression was not a condition of the shoulder that was on my radar screen prior to this course. 

That is one simple little example but there was a gob of nuggets for the nugget pouch and as always, I really walked away feeling that I will be better at my job on Monday. But it’s always that way. Even after just a 2-hour online course. It’s phenomenal.

Personal

Continuing the ongoing saga of hiring a front desk staff member in the year 2018. Here’s what all I’m going to say about it. Looks like my wife has found a new full-time job. Lol. Get the picture?

It looks like I may have a cool speaking gig coming up in February. Nothing solid but, if I were to come to your state convention or to some sort of event you are at, what topic along the vein of Chiropractic Forward’s typical content would you like to learn more about? 

If you are a regular listener and familiar with what we have been doing here this last year, I’d really appreciate it if you would take just a minute and email me at dr.williams@chiropracticforward.com and give me a little guidance. What topics would you want to see in a presentation?

I’m glad you’re here and hopefully, I didn’t ramble too much before getting to the meat and taters. Here we go with some vital information that we think can build confidence and improve your practice which will improve your life overall.

On To The Research

Picking up from last week, we want to start in on the changes disc herniations undergo when axial pressure is placed on them. In other words, what happens to disc herniations from the time the MRI is taken laying down to the point where the person sits up. 

I have to preface it all by saying go listen to last week’s episode which is #47, please. It tells you how it is very common in the medical field amongst even radiologists to assume or guess that there is no change in the disc or in the herniation when axial pressure is applied. Research tells us differently. 

This week we want to start with a paper called “Evaluation of intervertebral disc herniation and hypermobile intersegmental instability in symptomatic adult patients undergoing recumbent and upright MRI of the cervical or lumbosacral spines.” It was done by Ferreiro Perez, et. al[1]. and published in the European Journal of Radiology

How they did it

  • 89 Patients studied
  • 45 of them had their low back imaged
  • 44 patients had their necks imaged
  • The images were done in both the lying down position as well as the sitting.

What They Found

  • The overall combined recumbent (lying down) miss rate in cases of pathology was 15%
  • Overall combined recumbent underestimation rate in cases of pathology was 62%
  • Overall combined upright-seated underestimation in cases of pathology was 16%.

Wrap It Up

Upright-seated MRIs were seen to be superior to recumbent MRIs in 52 of the patients studied for conditions of posterior disc herniations and spondylolisthesis. Recumbent MRIs were only superior in 12% of the patients.

Next, this one is titled, “Effect of intervertebral disk degeneration on spinal stenosis during magnetic resonance imaging with axial loading” by Ahn et al[2].

Why They Did It

The authors in this paper were wanting to determine if disc degeneration will increase the severity of spinal stenosis when the spine is loaded with axial pressure. 

How They Did It

They had 51 patients with symptoms of neurogenic intermittent claudication and/or sciatica that had their MRIs loaded as well as non-loaded. 

The foramen involved were all measured for changes in sizes.

Wrap It Up

Here’s what they found, “More accurate diagnosis of stenosis can be achieved using MR imaging with axial loading, especially if grade 2-4 disc degeneration is present.”

AKA:” Seated or loaded MRIs are superior for assessing lumbar stenosis. 

Next, this one is by Willen[3] and it’s called “Dynamic effects on the lumbar spinal canal: axially loaded CT-myelography and MRI in patients with sciatica and/or neurogenic claudication.” It appeared in Spine Journal in 1997. 

They had 50 people with CTs, 34 were imaged with MRI, the imaging was performed laying down as well as axially loaded. 

They closed it up by saying, “Axial loading of the lumbar spine in computed tomographic scanning and magnetic resonance imaging is recommended in patients with sciatica or neurogenic claudication when the dural sac cross-sectional area at any disc location is below 130 mm2 in conventional psoas-relaxed position and when there is a suspected narrowing of the dural sac or the nerve roots, especially in the ventrolateral part of the spinal canal in psoas-relaxed position”

Next Paper

This one is by Kanno, et. al[4]. called “Axial loading during magnetic resonance imaging in patients with lumbar spinal canal stenosis: does it reproduce the positional change of the dural sac detected by upright myelography?” It appeared in Spine Journal in 2012. 

44 patients, with imaging in the supine position and then with axial load added. The dural sack was measured 

“The size of the sack was significantly reduced in the axially loaded imaging and the axial loaded MRI detected severe constriction with a higher sensitivity (96.4%) and specificity (98%) than the conventional MRI.”

Next paper

This one is by Danielson et. al. from 2001 called, “Axially loaded magnetic resonance image of the lumbar spine in asymptomatic individuals.” This paper appeared in Spine Journal in 2001 as well. 

MRIs were performed lying down as well as with axial load on the participants. The axial loading was performed lying down, face up with a compression device built for this study specifically. The diameter of the dural sack was measured to check for the differences. 

The authors said, “A significant decrease in dural cross-sectional area from psoas-relaxed position to axial compression in extension was found in 24 individuals (56%), most frequently at L4-L5, and increasingly with age.”

Pretty cool stuff right there people. 

I want you to go forward this week knowing what you get from listening to this podcast every week. You get things you can absolutely use and implement immediately. Some of you may gain confidence now that you know some research that you maybe didn’t know previously. Some of you may now be able to tell a patient that has a 5mm central posterior herniation that 5mm isn’t telling us the whole story. 

It’s telling us part of the puzzle but that discs respond to positioning and various stresses we put on the discs through our activities. 

Use it or lose it

This can give you some extra guidance in your recommendations when you consider disc herniations change and get worse, stenosis gets worse when the patient sits up or bends forward. 

If you aren’t up on directional preference exercises, McKenzie, and CRISP protocols, it’s time to get there folks. It’s time to get there. The anatomy absolutely responds to movement and positioning. 

Integrating Chiropractors

I want you to know with absolute certainty that when Chiropractic is at its best, you can’t beat the risk vs reward ratio because spinal pain is a mechanical pain and responds better to mechanical treatment instead of chemical treatments.

The literature is clear: research and experience show that, in 80%-90% of headaches, neck, and back pain, patients get good to excellent results when compared to usual medical care and it’s safe, less expensive, and decreases chances of surgery and disability.

It’s done conservatively and non-surgically with little time requirement or hassle for the patient. If done preventatively going forward, we can likely keep it that way while raising overall health! At the end of the day, patients have the right to the best treatment that does the least harm and THAT’S Chiropractic, folks.

Contact Us!

I want to ask you to go to chiropracticforward.com and sign up for our newsletter. We love to stay in touch and want to offer you discount specials when we get our educational products up and rolling. 

Send us an email at dr dot williams at chiropracticforward.com and let us know what you think of our show or tell us your suggestions for future episodes. Feedback and constructive criticism is a blessing and so are subscribes and excellent reviews on iTunes and other podcast services.

Y’all know how this works by now so help if you don’t mind taking a few seconds to do so.

Being the #1 Chiropractic podcast in the world would be pretty darn cool. 

We can’t wait to connect with you again next week. From the Chiropractic Forward Podcast flight deck, this is Dr. Jeff Williams saying upward, onward, and forward. 

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About the author:

Dr. Jeff Williams – Chiropractor in Amarillo, TX, Chiropractic Advocate, Author, Entrepreneur, Educator, Businessman, Marketer, and Healthcare Blogger & Vlogger

CF 047: Do Disc Herniations On An MRI Worsen When Sitting Or Standing (PART ONE)?

CF 035: Chiropractic & Disc Herniations

Bibliography

1. Ferreiro P, e.a., Evaluation of intervertebral disc herniation and hypermobile intersegmental instability in symptomatic adult patients undergoing recumbent and upright MRI of the cervical or lumbosacral spines. Eur J Radiol, 2007. 62(3): p. 444-8.

2. Ahn TJ, e.a., Effect of intervertebral disk degeneration on spinal stenosis during magnetic resonance imaging with axial loading. Neurol Med Chir (Tokyo), 2009. 49(6): p. 242-7.

3. Willen J, e.a., Dynamic effects on the lumbar spinal canal: axially loaded CT-myelography and MRI in patients with sciatica and/or neurogenic claudication. Spine (Phila Pa 1976), 1997. 22(24): p. 2968-76.

4. Kanno H, e.a., Axial loading during magnetic resonance imaging in patients with lumbar spinal canal stenosis: does it reproduce the positional change of the dural sac detected by upright myelography? Spine (Phila Pa 1976), 2012. 37(16): p. E985-92.

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